A coroner has expressed concern that a dentist's advice for his patient to be given a diet of soft foods was not heeded immediately.
Instead, 67-year-old Simon Lee, who was warded at Ng Teng Fong General Hospital (NTFGH) in a vulnerable state, was given meals based on a regular diet after having three teeth extracted on Jan 16 last year.
After another meal based on a regular diet a day later, a nurse heard Mr Lee coughing vigorously before falling unconscious.
Mr Lee, alias Lee Chwee Koon, died on Feb 18 that year due to a lack of oxygen and blood flowing to the brain, as well as pneumonia.
At the inquiry yesterday, Coroner Marvin Bay said Mr Lee's death was an unfortunate misadventure.
But he added: "It is nevertheless deeply concerning that dietary advice given by the dentist, Dr Bertrand Chew, was not immediately implemented.
"It would be clear that a patient in a situation of having undergone extensive dental surgery would be in a compromised and vulnerable state, with the ever-present risk of choking needing to be appropriately anticipated and monitored."
Coroner Bay said the soft diet was not immediately implemented as it was awaiting a dietitian's review.
However, based on currently known facts, he said it would not be possible to conclusively attribute Mr Lee's choking to the hospital's failure to provide him with a soft diet.
This was because Mr Lee had a number of "known serious and chronic maladies", including a previous stroke, past cardiac events and persistent coughing episodes.
Coroner Bay said Mr Lee had eaten regular meals on Jan 16 and 17 last year before collapsing.
He had been treated for bacterial sepsis on Jan 11 at the hospital. Sepsis arises when the body's response to an infection injures its own organs.
Dr Chew saw Mr Lee on Jan 16, as the sepsis could have been caused by poor oral health.
Three decayed teeth from Mr Lee's left upper jaw were extracted, and Dr Chew submitted a recommendation, which was recorded in an electronic medical report, for Mr Lee to be placed on a soft diet.
Coroner Bay noted that "NTFGH has taken positive steps following Mr Lee's demise... At the department level, there were efforts to improve the doctor-to-patient ratio to allow a speeding up of the processing of notes and orders".
In a statement, NTFGH expressed its condolences to Mr Lee's family.
A spokesman said the hospital has taken positive steps to review and strengthen its processes to improve patient safety and prevent similar incidents from occurring.